STATE OF WASHINGTON



354330023114000STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICESAging and Long-Term Support AdministrationHome and Community Services Division1492250238760HCS MANAGEMENT BULLETIN00HCS MANAGEMENT BULLETINPO Box 45600, Olympia, WA 98504-5600H18-036 – ProcedureJune 14, 2018 TO:Home and Community Services (HCS) Division Regional Administrators Area Agency on Aging (AAA) DirectorsFROM:Bea Rector, Director, Home and Community Services Division, ALTSASUBJECT:Compression GarmentsPURPOSE:To inform HCS and AAA offices of the process to assist individuals receiving long-term services and supports obtain compression garments (typically this is stockings).BACKGROUND:DSHS/ALTSA, and waiver programs in particular (i.e. COPES), are required by federal rule to be the payer of last resort for necessary services or items. Private insurance, Medicare, Apple Health (AH) or other available coverage must be used prior to a social service authorization. Case workers are required to ensure other available coverage is utilized prior to completing authorizations to providers.DME items have a national, standardized code associated with each item. The coding system is called the Healthcare Common Procedure Coding System (HCPCS). With the launch of ProviderOne Phase II, blanket codes were created to reduce the number of HCPCS codes a case worker would use to authorize for DME. Case workers use a blanket code to create an authorization for DME and vendors claim using the actual HCPCS code.Health Care Authority (HCA) WAC 182-543-6000 lists items that are not covered by Medicaid unless exceptional criteria are met. Included in the WAC are compressions garments. However, custom compression garments might be covered through an exception to rule (ETR) if specific criteria are met. There has been confusion regarding which compression garments might be covered through an ETR and when a social service authorization is appropriate without first receiving a denial from a medical benefit.WHAT’S NEW, CHANGED, OR CLARIFIED:Compression garments include several types of garments and could be used on the leg, arms, feet, etc. Stocking are the most widely used compression garments. Some compression garments are custom-made to an individual’s specific size and need, others are available “off the shelf” and others are available over the counter without a prescription or recommendation. Some types of compression garments are gradient, meaning the compression decreases from toe to knee. Gradient compression stockings are typically used for individuals who are ambulatory. They must be prescribed by a physician and are often used for individuals with venous insufficiency, ulceration due to chronic venous insufficiency, and deep vein thrombosis (DVT) as a treatment modality. AH will not cover compression garments that are full length (to the waist) or thigh high. AH may cover custom gradient compression knee-length stockings when medically necessary.Surgical stockings, also known as TED hose or anti-embolism stockings, are also compression garments, but are distinctive from gradient compression stockings. They are typically white and are often used post-surgery or for individuals who are bed-bound. Surgical stockings have less compression than gradient compression stockings and are used to prevent DVT. Surgical stockings are available over the counter, do not require a prescription, and are never covered through an AH medical benefit. There are situations when compression garments and surgical stockings should not be used. Individuals should always be evaluated by a medical professional to determine if compression garments are appropriate (including for items available over the counter).A “quote” is the vendor’s agreement to provide the service/item and the anticipated price prior to the delivery of a piece of equipment or service. An “invoice” is a document verifying the item or service was delivered or performed as agreed. The two terms are not interchangeable. The invoice verifying completion of the authorized service must be included in the client’s electronic case pression garments are not covered by Medicare so a denial is not required from Medicare. ACTION:Custom Gradient Compression StockingsWhen it is likely the client meets criteria for coverage from a medical benefit (excludes Medicare): If a physician has prescribed custom gradient compression stockings for the client, a DME vendor with a Core Provider Agreement with the Health Care Authority must request an ETR:For client’s enrolled in managed care, the vendor must follow the plan’s guidelines. For clients who are AH fee for service, the vendor must request an ETR from HCA using HCA Form 13-871 (attached below), following all protocols per the current DME Provider Guide. AH may approve compression stockings when all of the following are true:No other less costly alternatives will meet the client’s needs.The use of a compression garment is reasonable and necessary for the diagnosis or treatment of deep vein thrombosis (DVT), venous stasis or lymphedema.The client has been evaluated by a lymphedema specialist (the evaluation is a covered AH benefit).The stockings are measured, ordered and fit specifically for the client.The item that best meets the client’s needs is HCPCS A6549 (gradient compression stocking/sleeve, not otherwise specified).If the ETR is approved, the client receives the item and the vendor claims through the medical portal in ProviderOne per the billing guide.If the ETR is denied based medical criteria (not rejected for a lack of information provided by the vendor), the case worker can create an authorization using blanket code SA879 and place the payment status in “Reviewing”.For clients with FFC AH, a case worker can view the ETR in provider one (see attachment below)For clients with managed care AH, the vendor must provide a copy of the denial. Once the case worker confirms the client has received the custom gradient compression stockings, request an invoice from the vendor, and change the payment status on the authorization to “Approved”. The case worker should submit a Social Service Packet Cover Sheet to DMS with the invoice from the vendor attached. Non-custom Gradient Compression Stockings (off the shelf) and Surgical Stockings (TED hose) When a client does not meet criteria for coverage from a medical benefit for custom compression stockings (such as for edema): Obtain a recommendation from a medical professional (MD, RN, ARNP, etc.). This includes for items available over the counter. Request a quote from a vendor with the Specialized Equipment and Supplies (SES) contract, and authorize the item under code SA421 in “Reviewing” status: See the CFC Internet page for a list of providers with the SES contract.SES contracts are statewide. Some vendors may not offer compression garments.Once the case worker has confirmed the client has received the item, request an invoice (not quote) from the vendor, and change the authorization to “Approved” status. The case worker should submit a Social Service Packet Cover Sheet to DMS with the invoice from the vendor and medical recommendation paperwork attached. RELATED REFERENCES: HYPERLINK "" HCA DME Billing GuideHCA Form 13-871 ETR for Compression GarmentsMB H15-082: Specialized Equipment and Supplies and Assistive TechnologyMB H16-019: Contracted SES and AT providers and new DME/SES/AT Reference ToolsATTACHMENT(S):HCA’s Exception to Rule Request for Compression Garments\sHow to View Decisionsin ProviderOneCONTACT(S):Debbie Blackner, Ancillary Services Program Manager(360) 725-3231Benned@dshs. Jamie Tong, HCS Waiver Program Manager (360) 725-3293Jamie.tong@dshs. ................
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